The number of ways to improve one's appearance is ever-increasing. The spectrum includes efficacious medical non-surgical procedures such as therapeutic skin care regimens, laser rejuvenation with non-ablative and ablative lasers and liquid facelifts incorporating a combination of neuromodulator and tissue fillers. Natural-appearing beauty is the desire of many. The other end of the medical spectrum involves surgical approaches such as facelifts, which although often flattering, can change a person's appearance.
The buzz, fascination and growing popularity with platelet rich plasma (PRP) is related to the ongoing search for natural beauty. Platelet rich plasma allows a patients' own regenerative capabilities to enhance their beauty. PRP has multiple applications for the aesthetic and the non-aesthetic world such as orthopedics and veterinary specialties.
Bioactive Molecules found in α- Granules of Platelets
- Growth factors
- Adhesive proteins
- Clotting factors
- Fibrinolytic factors
- Proteases and antiproteases
- Basic proteins
- Membrane glycoproteins
Platelet rich plasma is the processed clear plasma that is separated from the red blood cells from the patients' own blood. This platelet rich plasma is very rich in growth factors and is about 3-5 times more concentrated in these factors than unseparated blood. It is has been associated with enhancement in healing.
Growth Factors That Have Been Identified in PRP
- PD-EGF: platelet-derived epidermal growth factor
- PDGF-A & B: platelet-derived growth factor
- TGF-B1: transforming growth factor
- IGF I, II: insulin-like growth factor
- VEGF: vascular endothelial growth factor
- ECGF: endothelial cell growth factor
- bFGF: basic fibroblast growth factor
- CTGF: connective tissue growth factor
These growth factors send an attraction signal to dormant unipotent stem cells in the skin, and then stimulate a repair response, enhancing the growth of new younger skin cells. This results in activation of the desirable skin rejuvenation process.
Platelet Rich Plasma in the aesthetic world has captured interest for skin rejuvenation from head to toe. It can be used on the scalp for hair restoration, on the face body for a more youthful glow or for scar reduction to reduce post inflammatory hyperpigmentation and improve skin texture irregularities.
When we first introduced PRP in our clinic several years ago, we injected it with and without other tissue fillers, particularly, hyaluronic acids. When a patient requested it without tissue fillers, it meant injecting several spots throughout the face usually spaced 1cm apart. This resulted in severe down time due to bruising. When patients described the benefits they felt, they were willing to go through the process again, even if bruising occurred.
Fortunately, as the aesthetic world advanced and new procedures and techniques became available, combining PRP with these procedures made sense. One of our most popular procedures to use the PRP with is micro-needling. The other application that we have instituted is PRP after CO2 laser resurfacing. Micro-channels are made in the skin using the needling device or the factional laser. At the completion of the micro-needling or the fractional CO2, the plasma is placed directly on the area treated with micro-needling or fractional laser, which penetrated through the micro-channels. The plasma rich in growth factors then communicate with the stem cells and start the process of rejuvenation with the growth of new more youthful cells. This has provided us with a means to deliver the PRP without the prolonged bruising of multiple injections. Blunt cannulas used for tissue fillers can also be used to rejuvenate the skin to deliver the PRP into the skin with minimized risk of bruising.Patients may appear to have mild sunburn immediately after the procedure. There may be pinpoint bleeding depending on the depth of treatment. This is usually not noticeable the following day. Partially due to the healing properties of PRP, there is minimal to no social downtime making this a very desirable option for patients. PRP can be used immediately after ThermiTight RF skin tightening (Injectable RF) procedure for the jowl and neck and other body parts to further enhancing the benefits of rapid healing and improved rejuvenation of a patient's own natural beauty. Adjuvant treatment with platelet-rich plasma is yet another advancement in the quest for efficacious skin treatment.
Aesthetic concerns of women go beyond the face and common body treatments. Over the last decade the term "Mommy Makeover" has increased in popularity. Going beyond that women have sought solutions to restore feminine youthfulness. Many don't bother reporting issues because they have accepted it as part of the aging process. Others due to cultural reasons are horrified to consider discussion or deny they have any issues. When bringing up the topic usually with their GYN practitioner, overactive bladder and stress incontinence are usually more acceptable topics to start the discussion. This may lead to discussion of vaginal laxity or looseness and other vulvovaginal issues like atrophy, lack of lubrication and dryness especially in the perimenopausal and menopausal ages. Orgasmic disorders and sexual desire are issues rarely brought up by patients largely due to acceptance with aging and hormonal decline.
ThermiVA is a revolutionary solution to restore feminine youthfulness for our patients who desire cosmetic enhancement of the vulva and have experienced the additional benefits of resolving their incontinence and have reported improved orgasms.
ThermiVA is a non-invasive procedure that requires absolutely no downtime. It utilizes a controlled radiofrequency platform. A small applicator with a temperature sensor at the tip is used to heat the tissue of the vulva and the vaginal canal. It uses temperature as a clinical endpoint to smooth skin and shrink mucosa. Heating the skin and mucosa promotes immediate contraction of collagen, immediate collagen remodeling and elasticity, and long term stimulation in producing new collagen. It is believed that incontinence and sexual function is improved by tightening of the pelvic floor, and the thermal input may stimulate chemotaxis and release of growth factors resulting in angiogenesis and neurogenesis.
ThermiVA is the current WOW of the practice. Patients describe the procedure with the sensation of a hot stone massage on the vulva and report a pressure sensation with virtually no pain in the vaginal canal. No pain medication or anesthetic is required. With more patients demanding non-surgical options that provide long-lasting results without downtime, patient satisfaction is extremely high.
"I am a 65 yr old woman that had experienced a decrease in sensation during sexual activity. My orgasms were lackluster if they even occurred. I heard of the ThermiVa procedure and had my first treatment 7 weeks ago. It was a short and comfortable procedure in a most aesthetic environment. There is no down time with this procedure so was anxious to see results. All I can say is "WOW." All of my vaginal nerve cells came alive. It was like having intercourse 20 years ago. A few weeks ago, I had the second procedure with this treatment. I noticed tightening of both the external labia and vulva. The sensation is phenomenal and I am truly satisfied."
"Walking, laughing, sneezing, coughing frequently caught me in the embarrassing situation of uncontrollable dribbling. After the 1st of 3 ThermiVa treatments the improvement was surprising. I didn't expect results to occur within hours of the procedure, but they were. I'm able to "clench" and stop mid-stream (just as a test). The month after the 1st treatment has been a relief from worry because I know I can control and prevent leakage."
Even among the healthiest women 75-85% suffer from the unsightly appearance of cellulite. It can even be seen in young teens and even infants. The cause of cellulite is not fully understood. It is virtually non-existent in men due to the thickness and structure of skin as influenced by male sex hormones. Some common theories include the following: poor circulation, herniated fat cells, water retention, fibrosis of connective tissue and accumulation of toxins in the fat tissue that may be a result of lack of physical activity or hormonal imbalances. Cellulite is defined as persistent subcutaneous fat causing dimpling of the skin, especially on women's hips and thighs. Some have classified different types, as in the appearance of surface skin depressions when a woman crosses her legs, versus a constantly present orange peel deformity.
The search for effective treatment of cellulite has been a source of frustration for women for years. Over the years claims have been made for various treatments including creams, brushes, dehydrating wraps, cellulite garments, magic pills and fitness contraptions. Our involvement with cellulite treatments started almost 20 years ago using Endermologie, which is still an effective short-term treatment using a system of vacuum and rollers. As laser aesthetics developed, awareness in treatment of cellulite grew and patients would demand the latest technology that they saw on TV. We found ourselves replacing previous cellulite technology with the latest, more advanced to attempt to provide the best solution for our patients. We have had as many as four devices at one time.
The results of cellulite treatment with our prior technologies are short-term and patients require multiple treatments on average one to two treatments a week for 6-12 weeks. Motivated patients accept this just to get mild improvement of the unsightly dimpling. We have a few patients who come routinely, seasonally, while a few come for treatment year round.
ThermiTight, a skin-tightening procedure that was developed to tighten skin on the face, neck, arms, abdomen and other parts of the body works by stimulating collagen production with radiofrequency energy. Radiofrequency energy is highly penetrating and can be delivered beneath the skin to stimulate collagen production-which can result in the tightening of skin and improve the appearance of cellulite. ThermiTight is a great option because it can improve tightness, smoothness, and produce more youthful-looking skin for all skin types.
Cellulite treatment with ThermiTight uses a thin electrode about the size of a piece of spaghetti to deliver carefully controlled radiofrequency energy and temperature to the subdermal tissue where cellulite occurs. It is performed using tumescent diluted local anesthetic to maintain patient comfort throughout the procedure. The procedure is minimally invasive and requires minimal downtime. A desired level of energy is delivered gently and evenly with continual monitoring of the energy delivered with control to reach a target temperature with safety and efficacy. Cellulite improvement with skin tightening is gradual and can be long-lasting. Results can be seen starting in a few weeks, but continue to improve up to one year.
Setting realistic expectations as in any aesthetic procedure is crucial and no guarantees can be made. Traditionally expectations have been set low for cellulite treatments and results are described as temporary. Genetics, hormone status, dietary and other factors may influence the patient's results. Some areas will improve better than others. Therefore it is quite noteworthy that some doctors using Thermitight treatment of cellulite started about three years ago and some patients have maintained results so far. We may finally have a longer lasting answer to cellulite improvement.
The new buzz in advanced permanent eyebrows is modern microblading micropigmentation also known as 3D Eyebrows, Eyebrow Embroidery or Feathering. Microblading is one of the oldest techniques used for cosmetic tattooing. In the last few years advanced modern tools have been developed making this technique a very sought after procedure that promotes a natural appearance. A small pencil-shaped hand instrument with disposable microblades comprised of microneedles is used. The microblading technique it a much more refined technique using much finer needles than tradition micropigmentation needles that have been used for decades. The quantity of needles and the blade types can vary.
The microblading micropigmentation hand instrument is used to delicately apply pigment as fine hair strokes with more definition and dimension resulting in the most natural-looking realistic soft eyebrows that can enhance a patient's natural features. Many patients are still afraid of getting their eyebrows tattooed largely as a result of people they know who have had cosmetic tattooing especially of the eyebrows that either had poor color selection but most often size, shape and the solid look of the tattooed eyebrows have dominated their faces.
As with tradition cosmetic micropigmentation, the eyebrow color will appear much darker the first week. After the scab formation peels, the resulting color is closer to the end resulting color. This technique should enhance color retention longer than tradition methods. The color should last about 1-2 years.
Microblading is becoming a very popular technique for cosmetic micropigmentation of eyebrows in various parts of the world including Asia, Europe and the US. Patients are seeking information on this exciting new technique from their hair stylists, cosmetic consultants and plastic surgeons. They are all seeking a natural soft appearance of eyebrows that can enhance their natural beauty that modern microblading can offer.
Stretch marks can be found on various parts of the body including the abdomen, thighs, hips, breasts, and arms, behind the knees, flanks and low back. Both men and women at different ages can develop these stretch marks.
Stretch marks can present differently depending on the skin type. They can range in color from white, silvery, pink, red, reddish purple to dark brown. Stretch marks usually appear more pink and red in the early stages and as time goes by, they become more white or silvery and appear indented.
It was felt that rapid stretch of the skin alone was the cause of stretch marks. It is now believed that an increase in cortisone, a hormone produced by the adrenal glands, contributes to the development of these unsightly parallel linear patterns. Elastic fibers in the skin may be weakened by cortisone. Genetic factors may also play a role. The physical stretching of the skin and hormonal factors play a role in the development of stretch-marks in pregnant women, teenagers during a growth spurt, body builders with substantial weight gain, use of corticosteroid creams or systemic steroids as well as those with various disease processes that affect the adrenal glands.
Over the years people have spent hundreds of dollars on useless lotions and potions that claim to make stretch marks disappear. Limited data is available for topical solutions that improve stretch marks. Tretinoin (Retin-A) has been shown to improve the appearance of stretch marks when used in the early stages. It works by stimulating collagen production. However, skin can become very irritated and patients need careful guidance on proper use of this product. Unfortunately it cannot be used during pregnancy.
Although nothing has proven to eliminate stretch marks, there are various lasers and light energy that can improve the appearance. Early treatment yields better results. Intense pulsed light (IPL) and V-Beam, a pulse dye laser can reduce the red appearance of the stretch marks. Fractional laser resurfacing vaporizes away a fraction of the scarred tissue and is replaced with new growth of collagen and elastin resulting in renewed skin with improved texture and color.
A device called Viora Reaction, utilizing bipolar radiofrequency, has surprised us unexpectedly in improving the appearance of stretch marks. In our clinic, we use this device for cellulite and skin tightening, and have seen improvement in stretch marks in the areas that we have treated. So far we have not had patients report hypo or hyperpigmentation. Response to treatment will vary among individuals.
Microneedling using the Dermapen has been a procedure that has yielded results beyond expectations. Different for the more traumatic dermal rolling, Dermapen utilizes groups of fine needles with adjustable depth of penetration depending on the condition to be treated. Collagen and elastin is stimulated by the microneedling to improve the appearance and texture of the skin. In addition, platelet rich plasma (PRP) can be applied topically immediately after the micro-channels are created, enhancing penetration of the PRP. This turns on the body's own regenerative process to repair the tissue being treated.
Realistic expectations need to be set. Results may vary depending on the severity of the stretch marks and the number of treatments. In many cases, a combination of modalities can yield the best results. These treatment modalities are costly and multiple treatments are usually required over a period of time. I tell all patients that stretch mark treatment is never 100%. Although these modalities can improve the appearance of the stretch marks, residual evidence of stretch marks may remain.
The "liquid facelift" has been an innovative answer to the demand for a rapid non-surgical way to enhance and rejuvenate the youthful volume that has diminished with aging. Over the last decade this has been accomplished with various fillers, neuromodulators like Botox and biostimulators that encourage growth of one's own skin components.
The "liquid facelift" has allowed us to understand and teach our patients about the natural aging changes of the face that relates to volume loss from diminished fat, muscle and unfortunately even bone as well as thinner skin. As a result of an increased understanding of facial aging, we have changed the manner in which we approach facial rejuvenation with volume. New products such as Voluma have entered the market to help us approach our patients differently in order to restore a more natural youthful appearance. Often diminished deep fat pads can be supplemented to approximate an appearance one had in the picture we carry of ourselves in our mind. We have come a long way since the days of superficially placed bovine collagen that lasted around three months to products that can last up to two years. We have moved away from chasing lines to global volume replacement from forehead to chin.
Although tissue fillers have been around over decades, many patients are still hesitant and fear looking unnatural and overdone. Over the years they have witnessed others who appeared "ducky", "monkey-like," "puffy" or "too full."
One of the biggest "giveaways" that many have witnessed is a mature woman with vertical lip lines that have been over filled with Juvederm or Restylane and distorted the shape of the upper lip in particular creating a "Marge Simpson" look with the upper lip protruding much past the lower lip. Patient's facial structures and ideal shapes are very different. The goal is to understand the volume change for each individual that is enhancing and flattering and often will not be detected by an observer as "having some work done."
Restylane Silk is now available to address the challenges that we have had with other fillers. Patients are sometimes not interested in getting fuller lips but simply want to address the vertical lip lines. In certain instances this will be all that needs to be done. In addition, patients who have lost definition of the lips due to the natural process of aging, environmental factors and habits can benefit with subtle enhancement-like lip definition. I often recommend patients a more "hydrated" appearance of their lips with Restylane Silk as the product, hyaluronic acid, will indeed hold more water in the area like a younger person does with the higher natural hyaluronic acid concentration in their skin.
Various fine lines around the face including the crows feet, glabella, forehead, nasal labial and cheek creases are ideal areas for Restylane Silk. Another one of my favorite areas to treat with Restylane Silk is along the infraorbital to the lateral orbital area that is below the eye over to the hairline area, often thin, crepey and sometimes showing fine lines of volume depletion. Some women have very thin skin overlying the bony structures and many of the other fillers have a higher risk of lumpiness and can cause a Tyndall effect, or bluish look where the filler is visible through the thin skin.
Restylane Silk is used much like bovine collagen fillers in the past to address vertical lip lines, lip reshaping and mild enhancement as well as fine lines in various fine lines around the face. Restylane Silk's advantage is it lasts about double the duration depending on the patients skin status and location of product placement.
It seems that we have gone full circle with availability of tissue fillers. Our focus went from chasing lines to plumping, volumizing and lifting and then back to the old way, filling lines softly and naturally in order to address needs of patients whose concerns are fines lines around the lips and face, lip reshaping and subtle enhancement.
When using the Restylane Silk to primarily address superficial fine lines one to two syringes can cover a lot of ground. Adding Restylane Silk can be the ultimate. finishing touch to a revolumized and contoured rejuvenated face.
Men and women often complain of disliking their profile due to their undesirable "double chin" or fullness of their neck due to submental and submandibular fat deposits under the chin or jawline. This condition is usually associated with genetics, aging and/or weight gain. It may be seen in patients within their ideal weight. The appearance of neck convexity or fullness negatively impacts these individuals, and they are often perceived as heavy or older.
Many patients assume that surgery is the only option. Now, these unmet needs can be addressed using a non-surgical option with injections to destroy fat cells. Injection of deoxycholic acid into the submental fat causes a denaturation of the fat deposits and dissolves the fat ,which allows the body to absorb it. This results in non-surgical contouring and sculpting of the neck. It is a procedure that we along with many other clinics have performed with variable results using deoxycholic acid compounded from various pharmacies.
Deoxycholic acid is produced in the body and helps the body absorb fats. Deoxycholic acid is a cytolytic drug. When it is injected into fat cells, it destroys the cell membranes. Practitioners must be properly trained to inject deoxycholic acid. Accidental injection into surrounding tissue can cause destruction of those cells as well for instance surrounding muscle and nerve cells.
Deoxycholic acid will now be available for the first time as an FDA approved submental contouring injectable drug called Kybella. Kybella has undergone clinical studies for safety and effectiveness. Over 20 clinical trials with more than 1600 patients treated yielded high patient satisfaction. The anticipated arrival will be later this month. Kybella is the first and only approved non-surgical treatment for reduction of submental fullness or convexity.
An ideal candidate for the treatment of the "double chin" with Kybella is a patient within their ideal weight with fullness of the neck, which is resistant to diet and exercise. Practitioners can customize the number of treatments to their patients according to the amount of submental fat. Most patients will require 2-6 treatments. After desired reduction, patients usually will not require re-treatment. An anticipated concern may be residual skin laxity, but the inflammation caused by the Kybella may cause variable degrees of tightening, so a secondary tightening procedure may not be required after the series of injections.
The injections elicit minimal pain response, but due to inflammatory changes of the fat cells initial swelling post-injection can be expected and may last approximately 2-5 days, so some down time may be expected. Other adverse reactions may include bruising, pain, numbness, erythema or formation of small areas of firmness at or around the injection site. Also the area may remain slightly more sensitive to touch for several weeks. Most of the adverse reactions were reported to be mild.
Warm weather brings out more revealing outfits that show off arms, the décolleté/cleavage, back, legs and midriffs. Patients are becoming more aware of sun protection, skin care and anti-aging measures for the face, but many times stop there. The chest or décolleté/cleavage accumulates sun damage over a lifetime, and blotchy mottling, discoloration with brown spots, redness, veins, skin texture irregularities, fine lines and wrinkles develop. With the loss of collagen and elasticity as we age and accelerated with sun exposure, our body positioning such as when sleeping can contribute to the formation of certain creases and lines in the décolleté.
Tank tops and revealing necklines can still be enjoyed using some anti-aging, rejuvenating measures. It's important to avoid or minimize further damage using sun protection. Skin care utilizing SPF and a combination of retinoids, bleaching agents, vitamin C, green tea, alpha hydroxyl acids, peptides and growth factors on a regular basis has been proven to improve skin quality and reverse signs of sun damage.
Many aesthetic treatments have also been beneficial in treating sun damage including but not limited to microdermabrasion, chemical peels, microneedling alone or with platelet rich plasma (PRP) to regenerate more youthful collagen using the patient's own growth factors to stimulate repair.
Light and laser devices are commonly used. Intense pulsed light (IPL) or Photorejuvenation can treat sun damage targeting red and brown discoloration as well as texture. Patients who have received a series of treatments have been reported to show more youthful gene patterns by skin biopsy. More stubborn pigmentation can be reduced with lasers that specifically target pigmented lesions. Ablative laser resurfacing such as fractional CO2 laser can effectively improve the texture of the skin by removing damaged skin and stimulating growth of new collagen in the cells and improving elasticity
Neuromodulators such as Botox and Dysport is a popular request for improving the appearance of lines and wrinkles as well as use of fillers such as hyaluronic acids to fill deeper lines and wrinkles. I have used bioactivators such as Sculptra (PLLA) to plump and improve skin quality by stimulating the patient's own collagen.
Patients desire skin tightening. The modalities we have used were primarily non-invasive radiofrequency. These non-invasive no-downtime include monopolar radiofrequency such Thermage or bipolar radiofrequency such as Viora Reaction. The radiofrequency is delivered to the surface of the skin, stimulates tissue contraction and new collagen growth resulting in tightening of the skin gradually over time without limitation of the patient's activity. The future looks promising for use of injectable RF such as ThermiTight RF for minimally invasive skin tightening of the décolleté and lifting of breast tissue without incisions.Multiple treatments may be required depending on the age of the patient when starting treatment, skin type, hormonal status, skin condition, sun habits, therapeutic and maintenance skin care and follow-up treatments. Patients can look forward to reduction of some of the sun damage that has accumulated over the years and be able enjoy younger more vibrant looking skin in their tank tops and revealing necklines.
Beauty of the upper face can be enhanced significantly using non-surgical techniques with neuromodulators and tissue fillers. Since the FDA approval of Botox for frown lines over a decade ago, patients have been well aware of the benefits of neuromodulators to improve the appearance of frown lines, crows feet and horizontal forehead lines. Typically patients think primarily of using neuromodulators to enhance the forehead but are not very aware of the benefits of adding volume to the forehead.
When patients are first treated with neuromodulators, they experience a "wow" with the results. As the natural process of aging takes place, loss of collagen and elasticity as well as loss of volume of the upper face requires the addition of tissue fillers to not only reduce the appearance of wrinkles but to return volume and shape to the area.
Patients are familiar with tissue fillers in the nasal labial folds due to the ads and brochures that circulate with images of the "parentheses. Since Sculptra, a collagen activator and now the newest hyaluronic acid, Voluma, was introduced, awareness in a more global approach to the face is increasing in popularity. An area that had been limited to neuromodulators for most practitioners is the forehead. Volume loss contributes a great deal to the loss of the "golden" proportions and shape to the forehead. When the forehead is rejuvenated and volume is replaced, a more youthful, well-rested face with natural appearing transitions is the outcome.
When patients start to express concerns of neuromodulators not working as well as they used to, especially in the upper face and around the eyes, it becomes important to evaluate volume loss in these areas. Frequently patients report that these areas are their last concerns, because their hair covers their temples and their bangs usually can cover their foreheads. Patients who have experienced ptosis of their eyelids who avoid neuromodulators in the forehead are more open to discussing this option.
A clear understanding of ideal shape and proportions of male and female genders and the concept of global facial rejuvenation in critical in educating the patient on how we can help them to look more refreshed, youthful and natural safely. When we understand what the ideal proportions of beauty, we can reflate and contour the face and deliver optimal results. Tissue fillers can treat glabellar or horizontal creases, temporal hollows, enhance eyebrow and forehead re-shaping.As a practitioner, understanding the anatomy of the face with respect to critical structures such as facial arteries, veins and nerves is important and enhances our confidence in providing a safe treatment minimizing pain and bruising. The experience for the patient is equally important as the outcome of results.
For several months, we have been offering a minimally invasive skin tightening procedure called ThermiTight injectable RF that allows us to tighten skin of the jowls and neck, upper arms, abdomen, knees and thighs. This device uses the ThermiRF radiofrequency platform for various applications with unique real-time precise thermoster controlled mircro-invasive and non-invasive treatments.
The most recent application is called ThermiVa. ThermiVa was introduced at the IMCAS World Conference as a breakthrough in non-surgical vaginal rejuvenation.
Years ago we offered laser vaginal rejuvenation in our clinic by OB/GYNs specialized in performing the procedure, creating a more aesthetic appearance, but it required surgery and involved downtime. The procedure is still performed today, but if given an option, most women would prefer a non-surgical approach without downtime.
ThermiVa requires a specific vulvovaginal radiofrequency applicator to work with the ThermiRF platform. ThermiVa is completely performed non-surgically and requires no anesthesia. There is no downtime required after the procedure. Gentle gradual heating allows the patient to tolerate therapeutic temperatures that stimulate collagen contraction and therefore skin tightening resulting in vulvovaginal rejuvenation. It's like performing a vulvovaginal "face lift" without surgery in an aesthetic clinic.
Vulvovaginal laxity, dryness, tissue stretching, nerve impairment, incontinence due to aging and loss of collagen are common issues that many women learn to live with and are often not discussed. Some women never even bring up these issues to their gynecologist thinking that nothing could be done anyway. Unfortunately, any one of these issues can make a woman feel less attractive, reduce her sense of well-being, impede sexual satisfaction and interfere with intimacy.
Red Alinsod, MD, FACOG, FACS, ACGE, a global leader of temperature controlled RF in vulvovaginal laxity, presented the findings of a pilot study using the ThermiVa procedure to treat vulvovaginal tissue using temperature controlled radio frequency. Alinsod is the Chairman of the ThermiGyn Women's Health Advisory Clinical Board.
Alinsod's study results showed both vulvar laxity and vaginal laxity improved significantly for all patients after the first treatment and continued to improve after the third and final treatment. In addition, participants reported improvement in sexual satisfaction, vulvovaginal tightening as well as improved vaginal moisture and improved continence as a result of the treatment. Dr. Alinsod noted, "The potential for a simple and safe temperature controlled RF device to treat vulvovaginal laxity, atrophic vaginitis, mild to moderate stress incontinence, overactive bladder, and orgasmic dysfunctions holds great promise and could be transformational.
The aging process affecting the vulvovaginal skin treated with a non-invasive method can now be provided as a simple no downtime office procedure to those seeking aesthetic enhancements and may provide improvement in sexual enhancement and sense of well-being.
the last decade we have seen a tremendous growth in the development of
non-invasive, non-surgical devices that promote skin tightening. The latest
addition to our armamentarium of rejuvenation includes the ThermiSmooth procedure,
which utilizes external radiofrequency energy for gentle, precise epidermal
heating. It’s the only system that the temperature can be adjusted for the
specific area of concern.
the skin temperature is sustained to approximately 40°-42°C, an inflammatory
response is created and stimulates the fibroblasts in the tissue to produce
collagen. The heat stimulates collagen contraction that results in tighter,
smoother skin over time. A precise amount of heat is required while appropriate
technique is used to maintain the temperature for 5-7 minutes over a small
zone. Multiple zones such as the forehead, around the eyes, cheeks, around the
mouth, jowls and neck can be treated.
most popular area requested is around the eyes. This is an area that usually
reveals our age, and there are not a lot of treatment options that address the
skin quality under the eyes and eyelids without downtime. This is an option for patients who cannot
afford the downtime of a more aggressive ablative fractional CO2 laser
resurfacing treatment. “Social downtime” is many times the reason for patients
to avoid certain treatments. Now we have ThermiSmooth, which can be performed
within a few minutes, and normal activities can be resumed immediately. Patients
can even be treated during their lunch break.
the ThermiSmooth procedure, a gel is applied to the skin. The hand piece is
usually moved in a circular motion over the gel until the target temperature
that is set (usually 42°C) is reached, and then a faster gentle sweeping motion
is applied to sustain the temperature while keeping the patient comfortable.
Sustaining the temperature for 5-7 minutes is key to the collagen stimulation.
to six treatments two weeks apart are usually recommended depending on the
patient’s desired results. Although some improvement may be seen immediately
after treatment, continued improvement in skin thickness and skin quality is
observed over several months after the ThermiSmooth sessions.
Laser skin treatments goes beyond rejuvenation, photoaging and wrinkles. Lasers can play an important role in scar revision. Scars can form anywhere on the body as a result of trauma, burns, surgery, cystic acne or some genetic predisposition such as spontaneous keloid formation.
Until the development of Fractional CO2, we were limited to pulse dye lasers to treat vascular and/or pigmented lesions or a variety of non-ablative lasers. These lasers help to improve the appearance of scars and are still today used in combination with fractional CO2 lasers. Different lasers and wavelengths cause different wound-healing responses. Non-ablative lasers provide lasers focus on heating the skin to trick body to sense that it has been injured stimulating a healing response, while ablative lasers actually removes some of the tissue causing a wound and allows the body to heal and form normal tissue. Fractional CO2 lasers are considered ablative as compared non-ablative lasers.
Adding the fractional CO2 laser to scar reduction has significantly enhanced the degree of improvement with fewer treatments as mentioned by Geronemus RG in Laser Surgery Medicine Journal 2008.
The fractional CO2 laser can penetrate thickened, non-flexible scar tissue, remove it and allow new tissue to form. Treatment has improved range of motion especially in burn scars. Therefore, scar revision in burn survivors not only improves the appearance of scars but improves functionality. Usually each treatment improves the scar. All skin types can be treated as long as appropriate parameters are used for the different skin types. Old and new scars can be treated.
Dr. Jill Waibel, who recently presented webinar sponsored by Lutronics, spoke on the Lutronics fractional eCO2 laser March 2015 and tissue repair on all types of scars is creating more awareness of reducing physically and emotionally disabling scars. She feels that there are many more scars that can be treated, and patients are not aware of the possibilities unless resources are brought to their attention. Due to modern medicine, many more are surviving burns and other traumatic injuries so there are many more scars to be treated.
Dr. Waibel feels early intervention is crucial. In the past we have been programmed to wait until the scar is more mature, but with early intervention, fractional laser co2 can actually prevent the more fibrous tissue formation. This concept can apply to most types of scars.
With increased awareness of the life changing benefits of scar remodeling with fractional CO2 laser resurfacing, more patients can be helped to lead more normal lives, improving physical function in every day home life or the work environment as well as improve their emotional well-being.
Women wear earrings over many decades. Various sizes, shapes and colors are coordinated with trends in fashionable wear throughout the seasons. When heavy earrings are worn repeatedly for long periods of time, the weight of the earrings can distort and elongate the opening of the pierced lobe. An obvious tear of the lobe may prompt a patient to seek treatment to repair the tear, but most are not aware of other ways to rejuvenate and reverse the appearance of aging that occurs.
As we become more advanced in understanding the concepts of facial aging and volume loss, we learn to venture into new areas of facial rejuvenation. Area patients rarely ask about or mention that we can and should introduce to the patient is rejuvenation of the ear lobes. This is especially important when we discuss pan facial rejuvenation with the goal to help the patient appear more balanced as we attempt to transition one area of the face to another smoothly.
During the assessment of the patient who is volume depleted, you will probably notice wrinkles pre-auricular and you may notice that the patient's earrings are tilted and pointing downward rather than forward. If you ask the patients to remove their earring, you will probably see folds and shadows adjacent to areas of convexity.
A youthful jawline may look longer with the cartilage reflecting light, which continues under the cartilage. If you follow the cartilage to the end of the jawline you can draw a continuous line where as the shadow created by lost volume under the cartilage gives a shorter appearance of the jawline. It takes a small amount of product to fill this hollow under the cartilage, and a small amount of product injected into the earlobe can also make it look more youthful with wrinkles or folds smoother with less shadowing. Injecting a lot of product into this area is not desirable and can make patients ears appear like Dumbo. Volumizing the earlobe and the shadow below the cartilage creates a line of light from the earlobe to the jawline giving the patient a more youthful look.
Rejuvenation of the ear lobes and surrounding skin is an area that is usually introduced to the patient by the practitioner. It is rare for a patient to bring this up. Many times ear lobe rejuvenation needs to be pointed out to patients using a mirror or photographs. Patients are usually amazed after they see the before and after photos and appreciate that you made the recommendation.
There is more pressure today for men to look fashionable, fit and well groomed. Male grooming products in the beauty industry are fast growing. Men are more concerned with their appearance and spending more time and money on themselves than ever before. Photos in the social media world have added to this pressure for males.
There are an increasing number of males seeking noninvasive and minimally invasive cosmetic procedures with little downtime to no downtime over the past few years. A desire to appear more refreshed, youthful and competitive along with a growing social acceptability of cosmetic procedures and increased safety and efficacy are all factors that contribute to the increase in male patients seeking more of these procedures.
A liquid facelift, using a combination of neuromodulators and tissue fillers, is growing in popularity in males as well as females. Much care is needed in the assessment and goal setting for males undergoing a pan-facial liquid facelift. The goal is towards maintaining a natural masculine appearance with smooth transitions from the top of the forehead to the jawline. All measures must be taken not to feminize a male face.
When discussing cosmetic procedures with a man, choosing words carefully avoids the fear of looking feminine. Men do not care to hear the word "beauty" and prefer masculine descriptions. They are comforted with words such as "well-rested" and "refreshed." They are less specific with details and simply want to look younger.
When using neuromodulators, dose needs to be adjusted to address muscle mass in the forehead, glabella and crows feet. On average, depending on the number of areas treated for the upper face, women may require 20-60 units whereas men may require 50-100 units. The male brow is more horizontal naturally while females prefer more arching of the brow. Men are not as obsessed with knocking out the crow's feet completely as women are.
The shape of the man's face is more squared or angular compared to a softer, heart-shaped female face. Bony structures and a more prominent brow are acceptable in males. Men have thicker skin generally and deeper injection techniques provide a more natural skeletal support versus skin plumping. When using tissue fillers, features such as the cheeks must not be over accentuated. The preferred area for the apex of the cheek on men is usually infra lateral versus more lateral for a female. Avoid placing filler in the high lateral cheek or over the zygoma. When attempting to reduce the amount of facial hollow causing shadows, especially in an athlete, the goal is to reduce the hollows to make the person look healthier without looking puffy.
The temples in male are generally more convex than a female's, and may require more tissue filler. As men and women get older and the shape becomes more skeletonized, it creates an older appearance, and the shape of the head appears more like a peanut. Treatment of temporal hollows making the area more convex can create a more masculine appearance in males using a variety of tissue fillers. Females also require fillers in this area but feminine features allow for a bit more concavity.
Men require more volume in the chin and jawline for support and definition of the squared mandible for a stronger masculine look.
As we see male patients in our clinics seeking these minimally invasive liquid facelifts, the anatomy of the masculine face needs to be kept in mind. We need to provide a positive experience to meet the needs of the growing male population and help them to meet their goal of a more refreshed, well rested, healthy, younger-looking appearance.
Acne, the most common skin condition, can result in acne scars, in up to 95% of those who get acne. This disfiguring skin condition can be devastating and affect self-esteem and self-confidence. Just a few weeks ago, for the first time in history the FDA has approved a tissue filler for treatment of acne scars. BellaFill, formerly Artefill, provides long-lasting scar correction.
Acne scars may present in a variety of ways. The technical names are boxcar acne scars, ice pick acne scars, rolling acne scars, hypertrophic and keloid scars. Patients can present with a combination of these types of scars. Acne scars are unattractive and difficult to conceal. Now patients do not have to "just live with it".
Treatment of acne scars also varies with the presentation of the scars. The more challenging acne scars to treat are boxcar scars and ice pick scars. Boxcar scars have more defined edges that appear like a box. Ice pick scars appear as small pits or enlarged pores on the skin.
Hypertrophic and keloid scars are raised areas that are well defined or go beyond the boundary of the scar. Although a patient may present with a variety of these scars, Bellafill is indicated for the treatment of rolling scars. An average of two visits using a syringe at each visit is recommended four to eight weeks apart. Bellafill can be used for all skin types and all ages.
Bellafill is made up of 20% PMMA microspheres and 80% bovine collagen. Correction is immediate. Bellafil helps to lift the scar to the level of the surrounding skin for a smoother appearance. As the bovine collagen dissipates the body's own collagen surrounds the PMMA matrix of microspheres and plumps the distensible rolling scars.
Results in the patient's self-esteem and confidence can change their lives. I had a patient come in for a follow-up appointment, and I was expecting to hear less than optimal satisfaction, because I could still see scarring. Getting back to realistic expectations that I prepared the patients for, I remembered that he had many ice pick and box scars which I had warned him would not respond like the rolling scars. Much to my surprise, the patient was ecstatic and could not express his appreciation enough.
Patients with depressed acne scars treated with Bellafil are often highly satisfied with long-lasting results especially if most of the scars are rolling and distendable scars without defined sharp borders.
Since the days of bovine collagen, more dermal fillers have been developed. There are a variety of hyaluronic acid fillers. The following are the most common: Belotero, Restylane, Perlane, Juvederm and Voluma. These HA fillers vary in consistency and duration of action depending on the cross-linking of the molecular structure. The higher degree of cross-linking, the longer it takes the body to break it down. With the patient's own collagen surrounding the PMMA microsphere matrix of Bellafill, the results are longer lasting.
Artefill is a lasting dermal filler approved by the U.S. Food and Drug Administration in 2006 for the correction of the nasolabial folds commonly known as "smile lines." Artefill, now called Bellafil is the first FDA approved dermal filler to provide long-lasting correction of moderate to severe atrophic distensible acne scars. Finally, there is long-lasting hope. Patients do not have to "just live with the scars."